Very importent for medical students

1. 1

2. HYPERTENSIVE EMERGENCY
DIAGNOSIS AND TREATMENT
Dr. M. Yaqoob Bahar, August 20, 2023

3. Hypertensive Urgency
• Severely elevated (BP>180/120 mmHg)
blood pressure without signs and
symptoms of acute end organ damage
• Often a mild headache
• Can be managed as an outpatient
• Can be managed with short acting oral
medications

4. Hypertesive Urgency
• rarely require emergency therapy
• Lower BP in a few hours
• Parenteral drug therapy is not usually
required; partial reduction of blood pressure
with relief of symptoms is the
goal.
• Effective oral agents are clonidine, captopril,
and slow-release nifedipine

5. Hypertensive Emergency
• Severely elevated blood pressure
(BP>=180/120 mmHg) with signs and
symptoms of acute end organ damage
• Require hospitalization

6. Hypertensive Emergency
• Damage Heart - CHF, MI, angina
Kidneys - acute kidney
injury, microscopic
hematuria
CNS - encephalopathy,
intracranial hemorrhage,
Grade 3-4 retinopathy
Vasculatur
e
Vasculature -
aortic dissection,
eclampsia

7. Epidemiology
• Hypertensive emergencies are common
– Occur in 1-2% of the hypertensive population
– But, 50 million hypertensive Americans
– 500,000 hypertensive emergencies/year
• Higher in the elderly
• Incidence in men 2 times higher than in
women

8. Initial Evaluation
• Assess for end-organ damage
• Vascular Disease
– Assess pulses in all extremities
– Auscultate over renal arteries for bruits
• Cardiopulmonary
– Listen for rales (CHF)
– Murmurs or gallops

9. Initial Evaluation
• Neurologic Exam
– Hypertensive Encephalopathy - mental
status changes, nausea, vomiting, seizures
– Lateralizing signs uncommon and suggest
cerebrovascular accident
• Retinal Exam

10. Retinopathy Grading
• Grade 1
– Mild narrowing of the arterioles
– “Copper Wire”
• Grade 2
– Moderate narrowing -
Copper wire and AV nicking

11. Retinopathy Grading
• Grade 3
– Severe Narrowing -
Silver wire changes, hemorrhage, cotton
wool spots, hard exudates
• Grade 4
– Grade 3 + Papilledema
• Grade 3 and 4 highly correlated with
progression to end organ damage and
decreased survival

12. Normal

13. Grade 1

15. Grade 3 Retinopathy

17. Lab Testing
• ECG
– LVH, look for signs of ischemia, injury, infarct
• Renal Function Tests (urine included)
– Elevated BUN, Creatinine, proteinuria, hematuria
• CBC
• CXR - pulmonary edema, aortic arch, cardiac
enlargement

18. Lab Testing
• Aortic Dissection?
– Suspect with severe tearing chest pain,
unequal pulses, widened mediastinum
– Contrast Chest CT Scan or MRI
• Pulmonary Edema/CHF
– Transthoracic Echocardiogram

19. Cerebral Blood Flow
Autoregulation
• Cerebral Blood Flow Autoregulation
– Cerebral Blood constant in normotensive
individuals over range of MAPs of 60 -120
mm Hg.
– In chronically hypertensive patients
autoregulatory range is higher
– MAP Range 100-120 to 150-160 mm Hg
• Autoregulation also impaired in the
elderly and those with cerebrovascular
disease

20. Management
• require substantial reduction of blood
pressure within 1 hour to avoid the risk
of serious morbidity or death
• It is the presence of critical multiple end-
organ injury that determines the
seriousness of the emergency and the
approach to treatment

21. • Goal - Reduce diastolic BP by 10-15% or to
110 mm Hg over a period of 30 - 60
minutes
• Parenteral therapy is indicated in most
hypertensive emergencies, especially if
encephalopathy is present.

22. • The initial goal in hypertensive
emergencies is to reduce the pressure by
no more than 25% (within minutes to 1 or
2 hours) and then toward a level of
160/100 mm Hg within 2–6 hours.
Excessive reductions in pressure may
precipitate coronary, cerebral, or renal
ischemia.

23. • To avoid such declines, the use of agents
that have a predictable, dose-dependent,
transient, and progressive antihypertensive
effect is preferable
• In that regard, the use of sublingual or oral
fast-acting nifedipine preparations is best
avoided.

24. Management
• Where?
– ICU with close monitoring
– Severe requires intra-arterial BP
monitoring
• Which Parenteral meds?
• Depends on the situation

25. Acute ischemic stroke
• is often associated with marked
elevation of blood pressure, which will
usually fall spontaneously. In such cases,
antihypertensives should only be
used if the systolic blood pressure exceeds
180–200 mm Hg, and blood pressure
should be reduced cautiously by
10–15% over 24 hours

26. Acute ischemic stroke
• If thrombolytics are to be given, blood
pressure should be maintained at less
than 185/110 mmHg during treatment and
for 24 hours following treatment

27. Intracerebral hemorrhage
• the aim is to minimize bleeding by reducing the
systolic blood pressure in most patients to 140
mm Hg within the first 6 hours.
• In acute subarachnoid hemorrhage, as long as the
bleeding source remains uncorrected, a
compromise must be struck between preventing
further bleeding and maintaining cerebral
perfusion in the face of cerebral vasospasm.
• In this situation, blood pressure goals depend on
the patient’s usual blood pressure.

28. ICH
• In previously normotensive patients, the
target should be a systolic blood pressure of 110–
120 mm Hg; in hypertensive patients, blood
pressure should be reduced to 20% below
baseline pressure.
• In the treatment of hypertensive emergencies
complicated by (or precipitated by) CNS injury,
labetalol and nicardipine are good choices since
they are nonsedating and do not appear to cause
significant increases in cerebral blood flow or
intracranial pressure.

29. Subarachnoid Hemorrhage
• Patients with subarachnoid hemorrhage
should receive nimodipine for 3 weeks following
presentation to minimize cerebral vasospasm. In
hypertensive emergencies arising from
catecholaminergic mechanisms, such as
pheochromocytoma or cocaine use, beta-blockers
can worsen the hypertension because of
unopposed peripheral vasoconstriction;
nicardipine, clevidipine, or phentolamine is
preferred.

30. SAH
• Labetalol is useful in these patients if the
heart rate must be controlled but should
not be used as first-line therapy because it
exhibits more beta- than alpha-blockade

31. Stroke
• HTN crises with acute or hemorrhagic
stroke
• With thrombolytic therapyBP
<185/110
• Without thrombolytic therapy15%
reduction in BP
• In hemorrhagic strokeSBP<180
• Urapidil,nicardipine,labetalol
• Avoid of nitroprusside ,hydralazine

32. Retinopathy
• HTN crises with advanced retinopathy
without reduction of consciousness
(labetalol,nitroprusside,urapidil,nicardipi
ne)
• HTN crises with encephalopathyBrain
edema(posterior region)+ reduce of
consciousness(10% reduction of BP in
first hour and 15% in next 12 hours to
160/110

33. ACS
• Acute coronary syndrome
• TNG +IV motoral or esmolol
• Labetalol or urapidil
• Nitroprusside is cotraindicated
• Acute heart failure Nitroprusside is
choice(+Lasix)

34. Misc
• Adernergic crisis
(pheochromocytomaphentolamine+be
ta blocker or nitroprusside ,urapidil
• Clonidine withdrawal clonidine
• Cocaine or methamphetamine- induced
HTN benzodiazepine +phentolamine

35. acute aortic dissection
• systolic blood pressure and heart rate
should be reduced within 30 minutes to
below 120 mm Hg and less than 60 beats
per minute, using a combination of
vasodilation and beta-blockade
– Esmolol + Nicardipine
• Nitroprusside can be used as well
•

36. CHOICE OF DRUGS
• Sodium nitroprusside is no longer the
treatment of choice for acute hypertensive
problems; in most situations, appropriate
control of blood pressure is best achieved
using combinations of nicardipine or
clevidipine plus labetalol or esmolol

41. Sodium Nitroprusside
• Disadvantages of sodium nitroprusside
– Decrease cerebral blood flow and increases
intracranial pressure
– Can reduce regional blood flow in coronary artery
disease
– Risk of cyanide toxicity
• Use when other agents not effective
– Monitor thiocyanate levels
– Avoid in renal or hepatic dysfunction
– Choice in Aortic Dissection,CHF
– 0.3-10 microgm/kg/min

42. Urapidil
• New central sympatholytic drug
• Selective alpha -1 receptor blocks
• Dose12.5-25 mg /kg bolus and 5-40
mg/hr iv infusion
• Choice in HTN after CABG&After
craniotomy

43. Labetalol
• Alpha&Beta Blocker(Beta>Alpha)
• Choice in Hypertensive
encephalopathy, Ischemic &
Hemorrhagic Stroke, Severe
preeclampsia/eclampsia, Aortic
Dissection
• 2-4 mg/min

44. Oral agents
• Patients with less severe acute
hypertensive syndromes can often be
treated with oral therapy. Suitable drugs
will reduce the blood pressure over a
period of hours. In those presenting as a
consequence of noncompliance, it is
usually sufficient to restore the patient’s
previously established oral regimen

45. • Clonidine
• Captopril
• Nifidepine

46. Subsequent Therapy
• When the blood pressure has been brought
under control, combinations of oral
antihypertensive agents can be added as
parenteral drugs are tapered off over a
period of 2–3 days

47. Thank you!
Questions?